Category Archives: Principles of Uncomplicated Exodontia

Technique for Multiple Extractions

Technique for Multiple Extraction

The surgical procedure for removing multiple adjacent teeth is modified slightly. The first step in removing a sin- . gle tooth is to loosen the soft tissue attachment from around the tooth (Fig. 8-5 1, A and B). When performing multiple extractions, the soft tissue reflection is extended slightly to form a small envelope flap to expose the’ erestal bone only (Fig. 8-51, C). The teeth are luxated with the straight elevator (Fig. 8-51, D) and delivered with forceps in the usual fashion (Fig. 8-51, E). If removing any of the teeth is likely to require excessive force, the surgeon should remove a small amount of buccal bone to prevent fracture and bone loss. After the extractions are completed, the buccolingual plates are pressed into their preexisting position with firm pressure (Fig. 8-51, F). The soft tissue is repositioned, and the surgeon palpates the ridge to determine if any areas of sharp bony spicules or obvious undercuts can be found. If any exist, the bone rongeur is used to remove the larger areas of interference, and the bone file is used to smooth any sharp spicules (Fig. 8-51, G). The area is irrigated thoroughly with sterile saline. The soft tissue is

FIG.8·S1-

FIG.8·S1-

 

 

 

 

 

 

 

 

 

 

 

 

 

FIG.8·S1-

FIG.8·S1-

cont’d F,Alveolar plates are compressed firmly together to reestablish presurgical buccolingual width of alveolar process. Because.of mild periodontal disease, excess soft tissue is found, which will be trimmed to prevent excess flabby tissue on crest of ridge. G, Rongeur forceps is used to remove only bone that is sharp and protrudes above reapproximated soft tissue. H, After soft tissue has been trimmed and sharp bony projections removed, tissue is checked one final time for completeness of soft tissue surgery. I, Tissue is closed with interrupted black silk sutures  cross papilla. This approximates soft tissue at papilla but leaves tooth socket open. Soft tissue is not mobilized to achieve primary closure, because this would tend to reduce vestibular height. ), Patient returns for suture’ removal 1 week later. Normal healing has occurred, and sutures are ready for removal. The broad band of attached tissue remains on ridge, similar to what existed in preoperative situation (see A) inspected for the presence of excess granulation tissue. If any is present it should be removed, because it may prolong postoperative hemorrhage. The soft tissue is then – reapproximated and inspected for excess gingiva. If the teeth are being removed because of severe periodontitis , with bone loss, it is not uncominon for the soft tissue flaps to overlap and cause redundant tissue. If this is the situation, the gingiva should be trimmed so that no overlap
occurs when the soft tissue is apposed (Fig. 8-51, H). However, if no redundant tissue exists, the surgeon must not try to gain primary closure over the extraction sockets. If this is done the depth of the vestibule decreases, which may interfere with denture construction and wear.
Finally, the papillae are sutured into position (Fig. 8-51, I and” f). Interrupted or continuous sutures are used, depending on the preference of the surgeon. . In some patients a more extensive alveoloplasty after  ultiple extracons is necessary. Ch-‘l.~ter 13 has an in- ?epth discussion of this technique. –

POSTEXTRACTION CARE OF TOOTH SOCKET

POSTEXTRACTION CARE OF TOOTH SOCKET

Once the tooth has been removed from the socket, it is necessary to provide proper care the socket should be debrided only if necessary If a periapical lesion is visible on the preoperative radiograph and there was. no granuloma attached to the tooth when it was removed, the periapical region should be carefully curetted to remove the granuloma or cyst. If any debris is obvious, such as calculus, amalgam, or tooth fragment remaining in the socket, it should be gently removed with a curette or suction tip (Fig. 7-72). However, if neither periapical lesion· nor debris’ is present, the socket should not be curetted.
The remnants of the periodontal ligament and the bleeding bony walls are in the best condition to provide for rapid healing. Vigorous curettage of the socket wall mereIy produces additional injury and may delay healing.

The expanded buccolingual plates’ should be compressed back to their original configuration. Finger pressure should be applied to the buccolingual cortical plate to gently but firmly compress the plates to their original position or approximate them even more closely if possible. This helps prevent bony undercuts that may have been caused by excessive expansion of the buccocortical plate, especially after first molar extraction.

If the teeth were removed because of periodontal disease there may be an accumulation of excess granulation tissue around the gingival cuff. If this is the case, special attention should be given to removing this granulation tissue with a curette or hemostat. The arterioles of granulation tissue have little or no capacity to retract and constrict, which leads to bothersome bleeding if excessive granulation tissue is left.

Finally, the bone should be palpated through the overlying mucosa to check for any sharp, bony projections.If any exist, the mucosa should be reflected and the sharp edges smoothed judiciously with a bone file.

To gain initial control of hemorrhage a moistened 2×2 inch gauze is placed over the extraction socket the gauze should be positioned so that when patient closes the teeth together, it fits into the space previously occupied by. the crown of the tooth. The pressure of biting the teeth together is placed on the gauze and is transmitted to the socket. This pressure results in hemostasis. If the gauze is simply placed on the occlusal table, the pressure applied to the bleeding socket is insufficient to achieve adequate hemostasis (Fig. 7-73). A larger gauze sponge (4 x 4 Inch) may be required if multiple teeth have been extracted or if the opposing arch is edentulous.

A, After extraction of single tooth, small space exists where crown of tooth was located. 8, Gauze pad (2 x 2 inch pad) is folded in half twice and placed into space. When patient bites on gauze, pressure is transmitted to gingiva and socket, C, If large gauze is used, pres~ure goes on teeth, not on gingiva or socket.

A, After extraction of single tooth, small space exists
where crown of tooth was located. 8, Gauze pad (2 x 2 inch pad)
is folded in half twice and placed into space. When patient bites
on gauze, pressure is transmitted to gingiva and socket, C, If large
gauze is used, pressure goes on teeth, not on gingiva or socket.

The extraction of multiple teeth at one sitting is a more involved and complex procedure. It is discussed in Chapter 8.

Modifications for Extraction of Primary Teeth

Modifications for Extraction of Primary Teeth

It is rarely necessary to remove primary teeth before substantial root resorption has occurred. However, when removal is required, it must be done with a great deal of care, because. the roots of the primary teeth are very long and delicate and subject to fracture. This is especially true because the succedaneous tooth causes resorption of coronal portions of the root structure and thereby weakens it. The forceps usually used is an adaptation of the upper and lower universal forceps, the no. 1505 and the no.  1515. They are adapted and forced apically in the usual fashion, with slow, steady pressures toward the buccal aspect and return movements toward the lingual aspect.

Rotational motions may be used but should be minimal and used judiciously with multirooted teeth. The dentist should pay careful attention to the direction of east resistance and deliver the tooth into that path. If the roots of the primary molar tooth embrace the crown of the permanent premolar, the surgeon should consider sectioning the tooth. Rarely the roots hold the crown of the permanent premolar firmly enough in their grasp to cause it to be extracted also.

Mandibular molars

Mandibular molars

The mandibular molars are usually two rooted, with. roots of the first molar more wide divergent than those of the· second molar. Additionally the roots may converge at the apical one third, which increases the difficulty of extraction. The roots are generally heavy and strong. The overlying .alveolar bone is heavier than the bone on any other teeth in the mouth. The combination of relatively long, strong, divergent roots with heavy overlying buccolingual bone makes the mandibular first molar the most difficult of all teeth to extract.

The no. 17 forceps is usually used for extraction of the mandibular molars; it has small tip projections on both beaks to fit into the bifurcation of the tooth roots. The forceps is adapted to the root of the tooth in the usual fashion, and strong apical pressure is .applied to set the beaks of the forceps apically as far as possible. Strong buccolingual motion is then used to expand the tooth socket and allow the ‘tooth to be delivered in the buccoocclusal direction. The linguoalveolar bone around the second molar is thinner than the buccal plate, so the second molar can be more easily removed with stronger lingual than buccal pressures (Fig. 7-70).

If the tooth roots are clearly bifurcated, the no. 23, or ( )whom, forceps can be used. This instrument is designed to be closed forcefully with the handles, there by squeezing the beaks of the forceps into the bifurcation. This creates force against the crest of the alveolar ridge on the buccolingual aspects and literally forces the tooth superiorly directly out of the tooth socket (Fig. 7-71).If initially this is not successful, the forceps is given buccolingual movements to expand the alveolar bone, and more squeezing of the handles is performed. Care must be taken with these forceps to prevent damaging the maxillary teeth, because the lower molar may actually pop out of the socket and thus release the forceps to strike the upper teeth (see Fig. 7-71).

Erupted mandibular third molars usually have fused conical roots. Because a bifurcation is not likely, the no. 222 forceps-a short-beaked, right-angled forceps-is used to extract this tooth. The lingual plate of bone is definitely thinner than the buccocortical plate, so most of the extraction forces should be ‘delivered to the lingual aspect. The third molar is delivered in the linguloocclusal direction. The erupted mandibular third molar that is in function can be a ‘deceptively difficult tooth to extract.

The dentist should give serious consideration to using the straight elevator to achieve a moderate degree of luxation before applying the forceps. Pressure should be gradually increased, and attempts to mobilize the tooth should be made before final strong pressures are delivered.

If curvature of premolar root exists, rotational extraction forces will result in fracture of curved portion of root, and therefore such forces should he minimized.

If curvature of premolar root exists, rotational extraction forces will result in fracture
of curved portion of root, and therefore such forces should he minimized.

A, Mandibular molars are extracted with no. 17 or no. 23 forceps. Hand positions of surgeon and assistant are same for both forceps.

A, Mandibular molars are extracted with no. 17 or no. 23 forceps. Hand positions of surgeon
and assistant are same for both forceps.

FIG 7-70

FIG 7-70

No. 23 forceps is carefully positioned to engage bifurcation area of lower molar. B, Handles of forceps are squeezed forcibly together, which causes beaks of forceps to be forced into ~ bifurcation and exerts tractional forces on tooth. C, Strong buccal forces are then used to expand sock- . et. 0, Strong lingual forces are used to luxate tooth further. E, Tooth is delivered in buccoocclusal direction with buccal and tractional forces

No. 23 forceps is carefully positioned to engage bifurcation area of lower molar.
B, Handles of forceps are squeezed forcibly together, which causes beaks of forceps to be forced into
~ bifurcation and exerts tractional forces on tooth. C, Strong buccal forces are then used to expand sock-
. et. 0, Strong lingual forces are used to luxate tooth further. E, Tooth is delivered in buccoocclusal
direction with buccal and tractional forces

Amalgam fragment left in this tooth socket after extraction; because surgeon failed to inspect and debride surgical field.

Amalgam fragment left in this tooth socket after extraction; because surgeon failed
to inspect and debride surgical field.

Mandibular premolars

Mandibular premolars

The mandibular premolars are among the easiest teeth to remove. The roots tend to be straight and conic, albeit sometimes slender. The overlying alveolar bone- is thin on the buccal aspect and somewhat heavier on the lingual side.

Extraction of mandibular left posterior teeth. Surgeon's left index finger is positioned in buccal vestibule, .reflecting cheek, and second finger is positioned in lingual vestibule, 'reflecting " tongue. Thumb is positioned under chin. Jaw is grasped between fingers and thumb to provide support during extraction

Extraction of mandibular left posterior teeth. Surgeon’s
left index finger is positioned in buccal vestibule, .reflecting cheek,
and second finger is positioned in lingual vestibule, ‘reflecting
” tongue. Thumb is positioned under chin. Jaw is grasped between
fingers and thumb to provide support during extraction

Jo provide support for the mandible to prevent f'XCP< sive temporomandibular joint (TMJ) pressures, a rubber bite block can be placed between the teeth on the contralateral side.

Jo provide support for the mandible to prevent f’XCP<
sive temporomandibular joint (TMJ) pressures, a rubber bite block
can be placed between the teeth on the contralateral side.

The lower universal (no. 151) forceps is usually chosen for the extraction of the mandibular premolars. The no. 151A forceps and the English style of forceps are both popular alternatives for extraction of these teeth.

The forceps is apically forced as far as possible, with the basic movements being toward the buccal aspect, returning to the lingual aspect, and, finally, rotating.Rotational movement is used more when extracting these teeth than any others, except perhaps the maxillary central incisor. The tooth is then delivered in the occlusobuccal direction (Fig. 7-68). Careful preoperative radio graphic assessment must be performed to assure the operator that no root curvature exists in the apical third of the tooth. If such a curvature does exist, the rotation all movements should be reduced or eliminated from the extraction procedure (Fig. 7-69).

A,When extrac~ing mandibular anterior teeth, no. 1Sl forceps is used. Assistant-reflects lip, and surgeon stabilizes jaw with left hand. 8, ForcepS is seated apically as far as possible. C, Moderate labial pressure is used to initiate luxation process. 0, Ungual force is used to continue expansion of bone. E, Tooth is delivered in labial-incisal direction.

A,When extrac~ing mandibular anterior teeth, no. 1Sl forceps is used. Assistant-reflects lip,
and surgeon stabilizes jaw with left hand. 8, ForcepS is seated apically as far as possible. C, Moderate
labial pressure is used to initiate luxation process. 0, Ungual force is used to continue expansion of
bone. E, Tooth is delivered in labial-incisal direction.

A, Extraction of mandibular premolar. Jaw is stabilized, soft tissue is reflect- -ed, and no. 151 forceps is positioned. B, Hand position is modified slightly for behindthe- patient technique. C, English style of forceps can also be used.

A, Extraction of mandibular premolar. Jaw is stabilized, soft tissue is reflect-
-ed, and no. 151 forceps is positioned. B, Hand position is modified slightly for behindthe-
patient technique. C, English style of forceps can also be used.

0, Forceps is seAted apically as far as possible to displace center of rotation and to begin expansion of crestal bone. E. Buccal forceps is applied to begin luxation process. F, Slight lingual pressure is used. G, Tooth is delivered with rotational, tractional force.

0, Forceps is seAted apically as far as possible to displace center of rotation and
to begin expansion of crestal bone. E. Buccal forceps is applied to begin luxation process. F, Slight lingual
pressure is used. G, Tooth is delivered with rotational, tractional force.

Mandibular interior teeth

mandibular interior teeth

The mandibular incisors and canines are similar in shape, with the incisors being shorter and slightly thinner and the canine roots being longer and somewhat heavier. The incisor roots are more likely to be fractured, because they are somewhat thin and therefore should be removed only after adequate preextraction luxation. The alveolar bone that overlies the incisors and canines is quite thin on the labial and lingual sides. The bone over the canine may be somewhat thicker, especially on the lingual side.

The lower universal (no. 151) forceps are usually used  to remove these teeth. Alternative choices include the no. 151A or the English style of Ashe forceps. The forceps beaks are positioned on the teeth and seated apically with strong force. The extraction movements are generally in the labial and lingual directions, with equal pressures both ways. Once the tooth has become luxated and mobile, rotational movement may be used to expand the alveolar bone further. The tooth is removed from the socket with tractional forces in a labial incisal direction (Fig. 7-67).

Mandibular Teeth

Mandibular Teeth

When removing lower molar teeth, the index finger of the left hand is in the buccal vestibule and the second finger is in the lingual vestibule, reflecting the lip, cheek, and tongue (Fig. 7-65). The thumb of the left hand is placed below the chin so that the jaw is held between the fingers and thumb, which support the mandible and minimize TMJ pressures. This technique ‘provides less tactile information, but during ‘extraction of mandibular teeth the need to support the ‘mandible supersedes the need to support the alveolar process. A useful alternative is to place a bite block between the teeth on the contralateral side (Fig. 7-66). The bite block allows the patient to help provide stabilizing forces to limit the pressure on the TMJs. The surgeon’s hand should continue to provide additional support to the jaw.

Maxillary molar

Maxillary molar

The maxillary first molar has three large and relatively strong roots. The buccal roots are usually relatively close together, and the palatal root diverges widely toward the palate. If the two buccal roots are also widely divergent, it becomes difficult to remove this tooth by closed, or forceps, extraction. ‘Once again the overlying alveolar bone is similar to that of other teeth in the maxilla the buccal plate is thin and the palatal cortical plate is thick and heavy. When evaluating this tooth radiographically, the dentist should note the size, curvature, and apparent divergence of the three roots. Additionally the dentist should look carefully at the relationship of the tooth roots to the maxillary sinus. If the sinus is in close proximity to the roots and the roots are widely divergent, sinus perforation caused by removal of a portion of the, sinus floor during tooth removal is increasingly likely, If this appears to be likely after preoperative evaluation, the  surgeon should strongly consider a surgical extraction.

The paired forceps no. 53R and no. 53L are usually used for extraction of the maxillary molars . These two forceps have tip projections on the buccal beaks to fit into the buccal bifurcation., Some surgeons prefer to’ use the no. 89 and no.90 forceps, which are sometimes called the upper cowhorn forceps. These two forceps are especially useful if the crown of the molar tooth has large caries or large restorations.

The upper molar forceps is adapted to the tooth and apically seated as far as possible in the, usual fashion (Fig. 7-64). The basic extraction ‘movement is to use strong,buccal and palatal pressures, with stronger forces toward the buccal than toward the palate. Rotational forces are not useful for extraction of this tooth because of its three roots. As mentioned in the discussion of the extraction of the maxillary first premolar, it is preferable to fracture a buccal root than a palatal root (because it is easier to retrieve the buccal roots). Therefore if the tooth has widely divergent roots and the dentist suspects that one root may be fractured, the tooth should be luxated in such a way as to prevent fracturing the palatal root, The dentist must minimize palatal force, because this is the force that fractures the palatal root. Strong, slow, steady, buccal pressure expands the buccocortical plate and tears the periodontal ligament fibers that hold the palatal root in its position. Palatal forces spould be used but kept to a minimum.

The maxillary second molar’s anatomy is similar to that 01 the maxillary first molar except that the roots tend to be shorter and less. divergent, with the buccal roots more commonly fused into a single root. This means that the tooth is more easily extracted by the same technique described for the first molar.

The erupted maxillary third molar frequently has conic roots and ·is usually extracted with the no. 210S forceps, which is universal forceps used for both the left and right sides. The tooth is usually easily removed, because the buccal bone is thin and the roots are usually fused and conical. The erupted third molar is also frequently extracted by the use of elevators alone. It is important to clearly visualize the maxillary third molar on the preoperative radiograph, because the root anatomy of this tooth is quite variable and often small, dilacerated, hooked roots exist in this area. Retrieval of fractured roots in this area can be very difficult.

A, Maxillary first premolar has two thin roots that are quite subject to fracture during extraction. B, Maxillary premolars are removed with no. 150 forceps. Hand position is similar to that used for anterior teeth. C, Firm apical pressure is applied first to lower center of rotation as far as possible and to expand crestal bone. 0, Buccal pressure is applied Initially to expand buccocortical plate. Apices of roots are pushed lingually and are therefore subject to fracture. E, Palatal pressure is applied but less vigorously than buccal pressure. F, Tooth is delivered in buccoocciusal direction with combination of buccal and tractional forces.

A, Maxillary first premolar has two thin roots that are quite subject to fracture during
extraction. B, Maxillary premolars are removed with no. 150 forceps. Hand position is similar to that
used for anterior teeth. C, Firm apical pressure is applied first to lower center of rotation as far as possible
and to expand crestal bone. 0, Buccal pressure is applied Initially to expand buccocortical plate.
Apices of roots are pushed lingually and are therefore subject to fracture. E, Palatal pressure is applied
but less vigorously than buccal pressure. F, Tooth is delivered in buccoocciusal direction with combination
of buccal and tractional forces.

A, When extracting maxillary second premolar, forceps is seated as far apically as possible. 8, Luxation is begun with buccal pressure. C, Very slight linqu.il pressure ~s used. D, Tooth is delivered in buccoocclusal direction

A, When extracting maxillary second premolar, forceps is seated as far apically as
possible. 8, Luxation is begun with buccal pressure. C, Very slight linqu.il pressure ~s used.
D, Tooth is delivered in buccoocclusal direction

A, Extraction of maxillary molars. Soft tissue of lips and cheek is reflected, and alveolar process. is grasped with opposite hand. B, Forceps beaks are seated apically as far as possible. C, Luxation is begun with strong buccal force. 0, Lingual pressures are used only moderately. E, Tooth is delivered in buccoocclusal direction

A, Extraction of maxillary molars. Soft tissue of lips and cheek is reflected, and alveolar
process. is grasped with opposite hand. B, Forceps beaks are seated apically as far as possible.
C, Luxation is begun with strong buccal force. 0, Lingual pressures are used only moderately. E, Tooth
is delivered in buccoocclusal direction

Maxillary second premolar

Maxillary second premolar

The maxillary second premolar is a single-rooted tooth for the root s entire length. The root is thick and has a blunt end. Consequently, the root of the second premolar fractures only rarely. The overlying alveolar bone is similar to that of other maxillary teeth in that it is relatively thin toward the bucca, with a heavy palatal alveolar palate.

The recommended forceps is the maxi nary universal forceps, or no. 150 some surgeons prefer the no. 150A. The forceps is forced as far apically as possible so as to’ gain ‘maximal mechanical advantage in removing this tooth. Because the tooth root is relatively strong and blunt, the extraction requires relatively strong movements to the bucca, back to the palate, and then in the
buccoocclusal direction with a rotational, tractional force (Fig. 7-63).

Maxillary first premolar.

Maxillary first premolar

The maxillary first premolar is a single-rooted tooth in its first two thirds. with a bifurcation into a buccolingual root usually occurring in the apical one third to one half. These roots may be extremely thin and’ are subject to fracture, especially in older patients in whom bone density is great and bone elasticity is small (Fig. 7-62). Perhaps the most common root fracture when extracting teeth in adults occurs with this tooth, As with other maxillary teeth, the buccal bone is relatively thin compared, with the palatal bone.

The upper universal (no. 150) forceps is the instrument of choice. Alternatively, the (no. 150) forceps can be used for removal of the maxillary first premolar.

Because of the high likelihood of root fracture, the tooth should be luxated as much as possible with the straight elevator. If root fracture does occur a mobile root tip can be removed more easily than one that has not been well luxated.

Because-of the bifurcation of the tooth into two relatively thin root tips, extraction forces ‘should be carefully controlled during removal of the maxillary first premolar. Initial movements should be buccal. Palatal movements are made with relatively small amounts of force to prevent fracture of the palatal root tip, which is harder to retrieve. When the tooth is luxated buccally, the most likely tooth root to break is the labial. When the tooth is luxated in the palatal direction, the most likely root to break the palatal root. Of the two root tips, the labial is easier to retrieve because of the thin, overlying bone.Therefore  buccal pressures should be greater than palatal pressure, any rotational force. should be avoided. Final delivery of the tooth from the tooth socket is with traction force in the occlusal direction and slightly buccal (see Fig, 7-62).